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Resuming a normal life: holistic care of
the person with an ostomy
Jennie Burch
Jennie Burch is Enhanced Recovery Nurse Facilitator, St Marks Hospital, North West London NHS Trust.
Email: jburch1@nhs.net
C
ommunity nurses regularly care for patients with a
stoma and in order to provide holistic care to such
patients, an understanding of stoma care is vital.
This article briefly explores a variety of aspects of stoma
care including why stomas are formed, what appliances can
be used and issues that might affect the ostomate once they
are discharged home from hospital.
Stomas
A stoma, also known as an ostomy, is an artificial, surgically created opening onto the abdominal wall to allow
the exit of faeces and urine. There are three main types
of stoma that the community nurse might encounter. The
most common is the colostomy, with 11000 formed in
the UK in 2006 (IMS, 2007). The least commonly seen is
the urostomy; there is also the ileostomy, which is being
increasingly formed due to surgical improvements and
the reduced need for a permanent stoma. A colostomy
is formed from the colon (large bowel) and will usually
pass flatus and soft, formed faeces into a closed bag. An
ileostomy is formed from the ileum (small bowel) and
will often pass about 800 ml of loose, porridge-like stool
and flatus throughout the day into a drainable pouch that
requires emptying between four and six times daily. A
urostomy is generally formed from a segment of ileum
and this gives the name ileal conduit. A urostomy will
pass urine and a small amount of mucous into a drainable
bag with a bung or tap on it and requires emptying four
to six times daily.
Abstract
A community nurse may often encounter an ostomate (person with a stoma)
but may not be regularly involved in their stoma care. This article explains
the main types of stoma, stoma appliances and indications for some
operations. Explanations are provided on some of the stoma appliances
and accessories and when these might be useful to the community nurse
and the ostomate. Stoma care is explained, including how to undertake
a basic stoma appliance change. Issues that community nurses might
be questioned about, such as diet and driving, are explored to assist the
community nurse in providing holistic care for ostomates.
KEY WORDS
Stoma w Colostomy w Ileostomy w Urostomy w Holistic care
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A healthy stoma is red or pink in appearance and usually round or oval in shape. An ideal colostomy should be
minimally raised above the level of the abdominal skin and
is often 30–35 mm in diameter and is generally formed in
the left iliac fossa. An ileostomy and a urostomy look similar (except for the output) they should ideally have a small
spout of about 25 mm and be about 28–30 mm in diameter
and they are formed in the right iliac fossa most commonly. A colostomy or an ileostomy can be temporary or
permanent, depending on the type of operation performed
and the indication for the operation, whereas a urostomy
is permanent. A colostomy or ileostomy will be either an
end or a loop stoma, again depending on the operation. A
urostomy is always an end stoma.
Colostomy
There are many reasons to form a stoma. These include:
wBladder cancer
wBowel perforation
wCrohn’s disease
wColorectal cancer
wDiverticular disease
wHirschsprung’s diseases
wImperforate anus
wSpina bifida
wTrauma
wUlcerative colitis.
A colostomy can be formed for a rectal cancer, diverticular disease, perforation or trauma. An operation that results
in a permanent end colostomy is an abdominoperineal
resection of the rectum. This operation involves the removal of the anus, anal canal, rectum and some of the distal
colon. A loop colostomy might be formed, for example in
the transverse colon; two ends are brought to the abdominal surface to protect or ‘defunction’ a lower anastomosis.
Ileostomy
An ileostomy is formed by bringing the end or loop of
small intestine (the ileum) out on to the surface of the
skin. An anterior resection involves the removal of some or
most of the rectum but the anal canal and anus are retained.
The two ends of the bowel that are left when the cancer is
removed are joined (anastomosed). However, as the join is
within the pelvis there is an increased chance of this join
leaking, which can lead to a potentially life-threatening
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An elderly colostomy patient with an abdominal wound being treated by a district nurse.
peritonitis due to faeces leaking inside the abdomen. The
surgeon may opt to perform a defunctioning ileostomy, also
called a loop ileostomy. The anastomosis is then defunctioned so that faeces do not pass through the new join and
thus eliminates the risk of peritonitis. A temporary ileostomy is then reversed or closed in a subsequent operation
at a later date, often 3 months to a year later, depending
upon the need for other treatments such as chemotherapy.
This operation can be performed both open (with a large
midline abdominal wound) or by laparoscopic or keyhole
surgery with multiple small incisions. The community
nurse might be requested to provide postoperative care for
the wound(s) and again when giving holistic care, might
also be requested to assist with any stoma-related issues at
the same visit.
Urostomy
A urostomy can be formed for a bladder cancer when
the bladder needs to be removed and the passage of
urine diverted through the abdominal wall. The operation
involves a cystectomy (bladder removal) with the ureters
remaining attached to the kidneys; the other ends of the
ureters are then joined to one end of a small segment of
ileum (which is isolated from the rest of the small bowel).
The end near the ureters is oversewn so that the urine does
British
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368 Journal of Community Nursing Vol ?, No not leak back into the abdominal cavity. The other end of
the ileum is brought out as the stoma (Nazarko, 2008). The
blood supply remains with the small segment (or conduit)
and the two ends of the small bowel are re-joined or reanastomosed so that the ostomate passes bowel motion in
the usual way.
Appliances and accessories
A stoma appliance – also known as a ‘bag’ or ‘pouch’ – is
a device designed to attach around the stoma and collect
the stomal output, i.e. faeces/flatus/urine, and contain
any odours, but to also be secure and skin friendly. An
appliance is made up from two parts, a flange and a pouch
part. The flange can also be called the base plate, face
plate or wafer and is the adhesive part that adheres to
the skin around the stoma (peristomal skin). The pouch
part is generally manufactured from plastic, covered in a
cloth-type outer layer and is opaque, although appliances
can also be clear.
Stoma appliances can be closed, drainable or drainable
with a bung. Each of these comes in a one-piece version
and a two-piece version. A one-piece appliance has the
flange and the pouch part joined and is removed in a
single piece. A two-piece appliance has the flange and the
pouch part separate and these are then joined (Williams,
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2006). Historically, the two parts were joined by rings
that clipped together. Since more recently, these two rings
adhere together.
The majority of stoma appliances have a flat adhesive
flange, but for ostomates with problem stomas such as
a retracted colostomy or a flush ileostomy/urostomy, a
convex appliance might be necessary. These should not
be used without a careful assessment as they can cause
ulceration around the stoma from the pressure of the
convexity, but are very useful in the appropriate situation
(Cronin, 2008a).
The stoma appliance is provided in hospital by the
stoma care nurse and this might work well indefinitely.
However, the appliance might actually become unsuitable
very soon after discharge home owing to changes in the
stoma or peristomal skin.
There is also a wide range of stoma accessories used for
a variety of different reasons. A stoma accessory is used
with a stoma appliance. Accessories can help secure the
appliance to the abdomen, might be used to remove the
adhesive or to protect broken skin, for instance. These will
be discussed later in the article.
There are also available alternatives to conventional
colostomy appliances including toilet disposable colostomy bags. These are specially designed to breakdown in
the toilet system. To hold back faeces for short periods of
time, stoma plugs (Cronin, 2008b) and other devices can
be used. Alternatively the colostomy can be irrigated to
wash out the faeces and then a small cap is required.
Stoma education
While in hospital (Colwell and Gray, 2007), a person with
a newly formed stoma (ostomate) should be taught to care
for their stoma and should have post-discharge followup by the stoma nurse (Fulham, 2008). Stoma training
quickly enables the ostomate to gain independence with
their stoma care and involves a number of simple steps.
These steps are basically as follows (although can vary):
wExplain the procedure to the patient and gain their
consent
wCollect all the stoma equipment (clean appliance,
measuring guide (if needed), pen (if needed), scissors (if
needed), cleaning/drying clothes or kitchen roll, warm
tap water without soap and a disposal bag
wEmpty the appliance if drainable
wGently remove the old appliance, supporting the
abdominal skin with one hand
wJoin the edges of the flange together to contain the
stomal output and place in the disposable bag
wGently but thoroughly clean and dry the peristomal
skin (being gentle with the actual stoma, which will
easily bleed, the stoma may also be active during this
time)
wMeasure the stoma (as the size can reduce in the first
eight weeks or with weight loss and can conversely
increase in diameter if weight is gained)
wCut the appliance to the required shape and size (ideally
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2-3 mm larger than the stoma)
wRemove the flange backing
wApply the flange to the peristomal skin
wSecure the adhesive to the skin by pressing firmly (start
at the stoma and work outwards)
wIf a two-piece appliance is used attach the bag
wHold the appliance onto the abdomen for 30-60 seconds to aid adhesion
wEnsure the fastening is closed (if appropriate)
wSeal the rubbish bag and dispose of it
wWash hands
wAvoid bending the abdomen for ten minutes after application to help adhesion (Trainor et al, 2003; Breckman,
2005; Rust, 2007).
The ostomate is also taught what is normal in respect of
their stoma, for example in appearance and stomal output.
Ostomates should also be taught to contact the stoma
specialist nurse in the case of problems with the stoma,
but in practice, it is often the community nurse that is
contacted for problems when the ostomate is reviewed
for another reason.
While still in hospital, ostomates are also instructed
on diet, but this may require further clarification postdischarge home.
Prior to discharge, the ostomate should be provided
with stock of appliances and accessories. Further supplies
are available on prescription and then collected from the
chemist or delivered by the chemist or a specialist delivery
firm. This is generally arranged by the stoma specialist
nurse for ostomates on discharge home from hospital.
To avoid wastage of expensive appliances, ostomates
should not collect large stockpiles as the shape of the
stoma changes post-discharge. In addition, supplies can be
bulky and have a limited shelf life – although this is generally several years in length. Usually one to two months’
supplies are adequate to be kept at home and re-ordered
each month. The prescription should be reviewed periodically to ensure that products are being used, and are
useful and appropriate.
Stoma care at home
Once the ostomate is discharged home, the actual learningto-live-with-the-stoma process begins. All advice is general
and may need to be specifically tailored for the individual
ostomate. If in doubt, the stoma specialist nurse can be
contacted for further advice by the community nurse or
the ostomate. Some ostomates have problems adjusting to
life with a stoma and the community nurse will possibly be
the person contacted or who notices the problem. It is ideal
when visiting and assessing an ostomate in the community
to try and ensure that holistic care is provided. However,
this is not always easily achieved when there are limited
resources and a lack of familiarity with stoma care can
result in caution on behalf of the nurse.
In a study by Williams et al (2010), it was discovered that
54% of ostomates experienced at least two stoma problems
on a regular basis. Areas that are likely to concern ostomates
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in the community are varied but may include:
wAppliances and accessories
wDiet
wResuming normal life
wSore skin
wPsychological issues.
Appliances and accessories: correct
usage
There are a multitude of stoma accessories that are used
in conjunction with stoma appliances. These are available on prescription. Accessories can be used to prevent
leaks, to remove adhesive and to protect the peristomal
skin. The nurse needs to carefully assess the situation to
ascertain whether accessories are necessary, and if so, that
accessories are used correctly. While it is important not to
waste products, as they are expensive, it is also necessary
to provide the ostomate with a secure appliance that does
not leak. Following a careful assessment by the community nurse, it still might be necessary to refer to the stoma
specialist or stoma care nurse (available in the local district
hospital), but it is possible to resolve some situations in
the community setting. Often the community nurse can
guide the ostomate on the correct usage of stoma products and educate them as necessary.
Sore skin is a likely reason for the ostomate to contact
the community nurse. For an example of a patient assessment, see Box 1. The assessment should include:
wStoma type?
wStomal output?
wDoes the appliance leak?
wWhere does the appliance leak?
wWhat length of time have the leakages/problems been
occurring?
wIs there a specific occasion that leads to leakage, e.g.
when in bed asleep?
wThe appearance of the peristomal skin (skin around the
stoma)
wskin colour?
wany breaks?
wextent of skin damage?
wAny recent changes that might have contributed to the
problem?
Leakage prevention
The community nurse might assess the ostomate and discover a leaking appliance. In this situation, accessories that
might be useful include seals (also termed washers; examples include Dansac GX-tra Seals, Coloplast mouldable
rings or Salts Healthcare secuplast mouldable seals), filler
paste (available in tubes or strips) and belts. Seals and filler
paste can be used to ‘fill’ skin dips or creases and are used
under the flange (Burch and Sica, 2008).
A seal is circular in shape and this can be used directly
around the stoma or broken into pieces to fill creases. Filler
paste can be used in the same way. A belt can be used to
more securely hold the appliance to the abdomen. There
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Box 1. Stoma care case study
A 70-year-old man with a temporary ileostomy formed 3 weeks
ago is being reviewed by the community nurse for an unhealed
surgical wound. He reports soreness around his stoma. On examination there is a 1cm ring of minimally red, broken skin directly
around the ileostomy. On questioning the ileostomy output is a
porridge-like in consistency, the appliance does not leak, the
soreness has been felt for about one week, there is discomfort
when changing the appliance and then again in the evening after
the appliance is replaced. Nothing has changed that he can think
of; in fact the faeces have thickened slightly as he is now eating
more food. The community nurse when removing the appliance
noticed that the hole in the middle of the flange was considerably
larger than the ileostomy size. The community nurse assessed the
problem to be due to cutting the flange aperture too large. The
nurse planned to re-measure the stoma and re-size the aperture
and re-teach as necessary and not to use any accessories in the
first instance, with review in three days. On examination at the
next visit the skin was healed and the ostomate reported feeling
more comfortable.
are often small loops on the edge of the flange and these
belt hooks are used to attach the belt to the appliance.
Adhesive removers
Adhesive removers such as CliniMed Appeel, or Opus
Healthcare’s Lift, which are available in wipes and sprays, can
help remove appliances. Caution should be used with adhesive removers which contain alcohol as this can sting broken
peristomal skin. For ostomates with fragile or damaged
skin, an adhesive remover can reduce any trauma or pain
associated with appliance removal. Another use for adhesive
removers is to remove the adhesive left on the abdomen by
the appliance.This can collect the fluff from clothes and leave
an unsightly ring on the abdomen. For people with sensitive
skin, it might be better to use a damp cloth to assist in appliance removal. Instead of an adhesive remover, a small amount
of soap can be used to remove residual adhesive but this can
dry the skin so it is not generally advocated and must be
carefully cleaned off the skin (Burch and Sica, 2005).
Skin protection
Accessories can also be used to protect the peristomal
skin. These are available as protective films such as Pelican
protect and 3M Cavilon (Black, 2007), wipes or sprays and
protective powder such as ConvaTec Orahesive powder,
Hollister Premium powder. Peristomal skin might require
a protective film if it is at risk of damage due to appliance
leakage, for example, while the problem is in the process
of being resolved. Broken peristomal skin might require
protective powder to help to ‘dry’ and protect the skin prior
to an appliance being adhered to the abdomen. Powder is
most effective if minimally used, so that only a very fine
coating is left on any broken areas of skin and none on the
intact, healthy skin (Burch, 2008).
Diet and stomas
The community nurse is likely to be asked for advice
regarding eating certain foods by an ostomate. In general,
an ostomate can eat and drink as usual. However, in the
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first few months, foods may cause problems that might
not occur subsequently. High fibre diets might not pass
so simply through a newly formed, oedematous stoma for
example. The general advice for all ostomates is to chew
food well and to drink about 1.5-2 litres daily of fluids.
Alcohol can be taken in moderation but might loosen the
stomal output (Pearson, 2008).
A colostomate (person with a colostomy) after an initial period can eat and drink anything. There is a risk of
constipation so the community nurse can provide dietary
advice to prevent this. It should be noted that oral laxatives can be used with effect if dietary manipulation does
not work. Although suppositories and enemas can be used,
they are prone to leak out of the colostomy before being
effective. Advice can be sought from the stoma care nurse.
An ileostomate (person with an ileostomy) can after an
initial period of about 6–8 weeks, also eat and drink most
foods. Some ileostomates can tolerate all diet while others
find they do not tolerate certain foods. Foods that tend
to be less well-tolerated are those that are high in fibre, as
these can cause loose stool for some ileostomates.
Poorly chewed food can cause a food bolus blockage.
This is reported by the ileostomate as abdominal discomfort and nil via the ileostomy. A blockage often simply
resolves by stopping eating and increasing oral fluids until
the blockage resolves and the ileostomy starts to function
again. If this method does not resolve the blockage, intravenous fluids and a nasogastric tube in hospital are generally necessary. The stomal output is looser in general than
it is prior to the operation, thus there is a loss of fluid in
the loose stool, making it essential that ileostomates have
at least 1.5 litres daily. There is also a loss of sodium, so
a little bit of salt added to meals daily is often advocated,
unless there is an already high dietary salt intake by the
ileostomate (Pearson, 2008).
Finally, a urostomate (person with a urostomy) is likely
to have a bowel disturbance initially following surgery, as a
segment of bowel is used to form the urostomy. This generally resolves in hospital but food should be well-chewed
prior to swallowing for a few weeks post-discharge home.
It is essential that urostomates drink well. Some find that a
glass of cranberry juice taken each day can keep the urine
clear and the mucous levels down.
Resuming a normal lifestyle
The community nurse may have several visits with a patient
after discharge from hospital and in this period of recovery,
it can be difficult for the ostomate to know how well they
are recovering and when they can resume a normal lifestyle.
In general, ostomates are encouraged to get up and dressed
each day. They are encouraged to mobilize as their tolerance
allows, but outside is ideal if the weather is good and there
are no contraindications to this. It is normal to get easily tired
in the initial post-discharge period and rest as needed. It is
also advised not to undertake heavy lifting or activities for 3
months after surgery.
Eating can often be better tolerated in the post-discharge
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period if it is little and often, ensuring a balanced diet to
aid healing. Long term, the advice is as above. Resuming
driving is variable; patients who had laparoscopic surgery
are likely to be able to start this sooner than ostomates with
the larger laparotomy wounds. It is important to ensure the
insurance company is in agreement then, it is usual to start
driving once an ostomate is confident with walking and
their strength has increased to allow them to perform an
emergency stop if needed. This is usually a minimum of 2
weeks after discharge home but can be considerably longer.
Sexual relationships can be resumed once the ostomate is
comfortable. For men who have had a urostomy, there may
be sexual problems such as erectile dysfunction and these
need to be discussed with the urologist. For women that
have had their rectum removed, there may be a change in the
angle of the vagina, potentially making intercourse uncomfortable in certain positions. It is possible to have children,
whichever partner has a stoma, and precautions need to be
taken if this is not desired. Concerns of the ostomate can
include embarrassment at potential sounds or worry about
appliance leakage (Ayaz and Kubilay, 2008) and advice can be
to ensure that the appliance is emptied (if appropriate) and
secure before starting sexual relations. Interestingly, the support of having a good relationship is beneficial to recovery
(Nichols and Riemer, 2008).
Work and exercises can be resumed quickly after discharge
home but not for all ostomates. Heavy jobs may not be
resumed for up to 3 months to allow the wound to ‘mature’
and strengthen. Heavy exertion may result in an incisional or
parastomal hernia (Thompson and Trainor, 2007). These are
swellings on the incision sites or around the stoma respectively. Prevention can include the use of a hernia support belt
in conjunction with abdominal exercises, which the stoma
care nurse can advise upon. Walking is advised during hospitalization and therefore, from the day of discharge.
Holidays in Britain or abroad can be taken. The general
advice is to take more than the number of appliances used
in the same period, twice as many as usual is advocated. Also,
if the ostomate is flying, they should have their appliances in
their hand luggage in case of lost luggage. It is recommended
to see the stoma specialist nurse for travel advice.
Psychological issues
Although in general most ostomates seem to cope well
with their stoma, some can have problems adjusting to it.
It has been suggested that the initial phase of adjustment
is very important (Bossom and Beard, 2009). Issues can
include problems with the way the individual perceives
what they look like to others, although many ostomates
wear tight-fitting clothes without the stoma being visible.
Others worry about issues such as sex (Simmons, 2008).
On some rare occasions, ostomates require more intensive
treatment for these issues such as sessions with a counsellor.
There are also support groups available nationally and often
locally (Hulme and Brierley, 2007). The community nurse
can alert the general practitioner if psychological issues are
suspected to be a problem.
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Conclusion
In summary, the community nurse should provide holistic
care to ostomates, even if the primary reason for the contact
is not the stoma. There can be a number of ways in which
the community nurse can assist; this can include advice
about stoma appliances or accessories and their correct
usage. Nurses can also give advice on postoperative recovery including normal expectations, which include resumption of activities following discharge home from hospital.
Although advice in general works for all ostomates, a young
person is likely to regain strength faster than an older one. If
further assistance is necessary by the nurse or the ostomate,
the stoma specialist nurse can be contacted in the local
hospital for advice.
BJCN
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British Journal of Community Nursing Vol 16, No 8
LEARNING points
w A colostomy is the most common type of stoma, followed by ileostomy and
urostomy
w Stoma appliances are varied but essentially closed for a colostomy,
drainable for an ileostomy and drainable with a tap or bung for a urostomy
w Community nurses should aim to give holistic care when with their stoma
patients
w Concerns about diet, sore skin and resuming lifestyles are common for
people with a stoma once discharged home from hospital
Fulham J (2008) A guide to caring for patients with a newly formed stoma in
the acute hospital setting. Gastrointest Nurs 6(8): 14–23
Hulme E, Brierley R (2007) Living with a colostomy. Gastrointest Nurs 5(2): 22–4
IMS (2007) New Stoma Patient Audit GB – August 2007
Nazarko L (2008) Caring for a patient with a urostomy in a community setting.
Br J Community Nurs 13(8): 354–61
Nichols TR, Riemer M (2008) The impact of stabilizing forces on postsurgical
recovery in ostomy patients. J Wound Ostomy Continence Nurs 35(3): 316–20
Pearson M (2008) Nutrition. In: Burch J (ed) Stoma care. Wiley-Blackwell, West
Sussex
Rust J (2007) Care of patients with stomas: the pouch change procedure. Nurs
Stand 22(6): 43–7
Simmons KL (2008) Improving stoma surgery outcomes: more patient choice,
more psychological support. Gastrointest Nurs 6(4): 21–5
Thompson MJ, Trainor B (2007) Prevention of parastomal hernia: a comparison
of result 3 years on. Gastrointest Nurs 5(3): 22–8
Trainor B, Thompson MJ, Boyd-Carson W, Boyd K (2003) Changing an appliance. Nurs Stand 18(13): 41–2
Williams J, Gwillam B, Sutherland et al (2010) evaluating skin care problems in
people with stomas. Br J Nurs 19(17): S6–S15
Williams J (2006) Stoma care part 1: choosing the right appliance. Gastrointest
Nurs 4(6): 16–19
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